M.t.a.s. Insurance Program Application - Dusyk & Barlow Insurance Brokers Ltd./ Lackner & Mclennan Insurance Form

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M.T.A.S. INSURANCE PROGRAM APPLICATION
DUSYK & BARLOW INSURANCE BROKERS LTD./
LACKNER & MCLENNAN INSURANCE
1. Name __________________________________ Phone:
Work (___)___________
Email Address ________________________________
Home (___)___________
2. Mailing Address ___________________ Town ___________ P. Code ________
3. Business Location ___________________________________________________
(street address or legal description please)
NOTE: If you have other clinics, please list on a separate sheet.
4. Year and Place of Graduation ________________________________________
5. M.T.A.S. Membership Number (required) _______________________________
6. Where did you practice previously? __________________________________
7. Do you operate any infra-ray, diathermy, tanning booth, quartz lamps
or heat lamps? ______________________________________________________
8. Do you have any physical disability? ________________________________
9. Please describe any other business operations you conduct. __________
_____________________________________________________________________
10. Is any claim or suit pending, or has any suit or judgement been enter-
ed against the applicant, or has any claim been paid by the applicant
for damages on account of any actual or alleged malpractice, error or
mistake occurring in the practice of his or her profession?
If so,
please elaborate in an attached letter.
______________________________________________________________________
The applicant hereby applies for insurance coverages as outlined.
The
information given herein is certified to be true.
I acknowledge that
coverage may be null and void if I make a material misrepresentation of
facts that would affect the insurer's judgement of my risk factor.
Signature ________________________________
Date _________________________
2005/09

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